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Cultural Factors In The Etiology

Ii

CULTURAL FACTORS IN THE
TIOLOGY OF MENTAL DISORDER
AND THEIR IMPAC
ON CLINICAL
SYMPTOMS AND INTERVENTION

INTRODUCTION
culture on mental disorder has drawn attention of researcher in the
Culture has been defined in different way s
different
differences
ethnic
group of researcher views culture in a wider
and social economic differences
different

o:.tt,>rn''lt

assess
in that direction.

evidence for a better unlderstanclmg
rm.OHlgs that have been documented in the literature
been based on American culture
a reVIew see n.d'''xu.u.

........·"Plnt

article

cultural factors
reviews a small number
culture
the
and

the way

jplluence
studies. The discussions
One
of

9

discussions will review the possible roles of culture in intervention. Discussion on care and
after care of mental disorder in this mcile is excluded due to the limitation of space.

METHODOLOGICAL PROBLEMS
Research in the field of mental disorder faces a number of methodological problems which
frequently complicate the interpretation of the findings. Two areas that are considered as
major problems. The iust is how to deime the case categorized as mental disorder. The
second is how to collect data after the definition of case has been settled.

How to dame a case as mental disorder.
The biggest problem in studying mental disorder from cultural view-point is mental
disorder is defined differently from one culture to another. The problem arises because of
the marked differences regarding the standard of normal behavior. In some cases, certain

manifest behaviors that are perceived as abnormal in the Western cultures, have been
considered as normal by a particular culture. For example, suspiciousness has been regarded
as normal for Dobuans (BenedictJ934 cited from Kiev, 1969), while in Western cultures it
is regarded as one of clinical symptoms. In such instance it is difficult to decide what can be
defined as normal. Kiev (1969) suggested to use cultural standard in solving this problem.
Based on the argument that symptoms of disorder are either distressing to the patient or to
the people surrounding him, Kiev suggested. research should be done in order to find the
standard of behavior that is fitted to that particular cultnre. The implication of Kiev's
suggestion, from the view-point of the present writer, is that research utilizing universal
standard of mental health that classifies any deviant from this standard as a mental disorder,
should be abandoned. Secondly, research on any particular culture should be a continuos
process, since values in any particular culture may change from time to time which causes
the cultnrally based standard ever changing.
The second problem that always arises regarding the deimition of the case is what
constitntes the prevalence (the number of cases in any particular time). Using HeUer's
(1981) classification, there are four ways for defining the prevalence : number of hospital
admission, number of person received psychiatric treatment, number of person who are
categorized by personality inventories as abnormal, and number of person who admit
subjective unhappiness. The probJem arises because not any of these criteria is satisfactory.
Utilizing mental hospital admission, for example, excludes those who are mentally disorder

but do not go to hospital If the prevalence is based on the admitted subjective unhappiness,
then the individuals who do not admit theiF feelings will be excluded.
Cross cultural studies on mental disorder that have been done so far utilized different
criteria in determining the prevalence. For example Enright and laeckle (1963) used mental
hospital admission. Eaton and Woo (1953) utilized the numbeF of those who received
psychiatric treatments. Leighton (1969) based the prevalence on the number of subjective
unhappiness admitted. Schwab, Bell, Warheit, and Schwab (1979) used personality

10

Cultural Factors: In The Etiowgy

inventory. Due to differences in criteria, it creates problem in integrating the findings of
cross-cultural studies. The problems become more complex if the method for collecting data
is also different from one study to another study
Data collection technique
Dohrenwend and Dohrenwend (1974) listed several techniques that have been used in
conecting mental disorder cases. The techniques were categorized into two broad
categories, personal judgment and objectively scored measures.
With regard to personal judgment there are two general approaches that have been used in

making the evaluations. First. a single psychiatrist or a small team headed by a psychiatrist
directly interviewed community residents. and based on the interview a clinical judgment
was made. The second approach. a psychiatrist or a team headed by a psychiatrist directly
mtervlewed community resident. In one variation of tllls approach, a psychiatrist instead of
directly interview the resident he or she requested another psychiatrist, clinical
psychologists, or layman interviewers to conduct the interview. Based on the result of the
interview, a psychiatrist made the judgment regarding the potential clinical symptoms. The
problem with this approach. the one who judged the result of interview tend to be over
impressed and overestimated the pathology if working from written records alone
(e.g.Gottheil. Kramer and
1966).
Objectively scored measures have been used by a growing number of investigators. The
Langer's (1962) 22 item-psychiatric-screening instrument is the one widely used. A rather
similar but less widely used measure is a 20 item Health Opinion Survey questionnairre
(Macmillan. 1957) Since about half of the items in these instrument were physiological in
and depression. these
nature, while the other half were items that best for detecting
instrument serve best for studying neuroses but not for psychoses. The utilization of these
instrument in clinical studies has created controversial issue. The proponents support the
of the

the
to discriminate
utilization on the basis of the
and the relatedness of scores with demograp.rjc
The instrument have been criticized due
distress in some groups, items are ｣ｏｬｮｰｯｵＺ｛､＼ｾ＠
& Dohrenwend,1967).
The utilization of these various techniques produces different estimates of true prevalence
of mental disorder. The inconsistencies of the various techniques may cause uncertainty
of inference made with regard to the relationship between cultural
regarding the
factor and mental disorder. This uncertainty becomes more pronounced if the techniques
that has been used is a mere translation of the western instruments which its validity and
reliability for a particular culture was never assessed.

11

Cultural Factors In The Etiologl'

Research paradigm

Mostly studies investigating the effect of culture on mental disorder exclude variables other
than cultural variables. Physical settings of the society and genetic factors are among those
that were frequently excluded. As has been found in some studies these variables are related
to the occurrence of mental disorder. The effects of sunshine, weather, lunar position on
mental disorder incidence have been found by a number of studies (for review see Moos,
1976) Genetic factors and its influence on menta! disorder have also been demonstrated
(for review see Hurst,
Due to the facts that these variables are influential. then, in
any cross cultural study of mental disorder these variables should be included. Heller and
Monahan (1
discussed the need to change the orientation regarding the etiology of
mental disorder from a single-cause orientation to a multi-risk-factor orientation. The
suggestion proposed by Heller and Monahan can also be applied to cultural study of mental
disorder This approach is expected also to give solution to the controversy regarding the
role of genetic and environmental factors on mental disorder.
The second feature of cross-cultural study of mental disorder is cross-sectional. this
paradigm can not detect the causes of change in incidence rate of mental disorder in a
particular culture. For example, Kiev (1969) reported that in 1934, III cases of 'imu'
(exotic disorder) were found among 17.500 Ainu in Japan. In 1958, in this same ｡ｲ･ｾ＠
anly

one case was found This type of phenomenon can only be understood if there is a follow up
study. Due to the facts that other variables (e.g. sunshine, weather, lunar position) have
study is a better paradigm.
effects on the incidence of mental disorder. then a
addition,
the effects of cultural change can also be
it""""",,-,,. This
detect the
of mental
such
the

issues attract our attention.
what cultural variables

"","V"",""

can be

culture can be etiological factor

may be seen from several
may see some aspects of culture as a source of stress and
fmstration, since they control the demand of primitive impulses, In the language of
psychoanalytic theory, culture is the Super-ego which inhibits any demand which is socially
unacceptable from the Id. If stress and frustration accumulate to a degree that can not be
tolerated by the individual, then menta! disorder symptoms develop.
From learning-theory perspective, cultnre can be etiological factor because culture provide
channel for reinforcing the abnonnal behavior. Kiev (1969) argued that a certain symptom

12

Cultural Factors In The Etiology

of mental disorder develop, because this symptom is rewarded in that particular culture. For
example, in Haitian culture there is a kind of ritual activity that lead to trance accompanied
by a reduction of higher integrative functions such as articulate speech, socia! inhibition.
and muscular coordinatioll increase of reflex behavior such as trembling, convulsive
movement. muscle
and teeth grinding. These behaviors are tolerated and
applauded in ceremonies. Those eccentric behavior are culturally recognized and "'f'r'pntpri

ways of going crazy.
What cultural vari.ables can be etilogical facto,·
speculated that there are three broad variables that can be
Wittkm.ver and Dubreuil (l
considered as etiological factors cultural contents refers to all beliefs. values. norms,
attitudes, and customs in a people's culture. Social organization is the network of regular
and
long standing interactions between members of society. Sociocultural change
is any change in the cultural content and social organization. Wittkower and Dubreuil did
Wittkower and Dubreuil.
not provide enough evidence to support the speculations made
In interpreting the research
precautious actions should be taken. First, the findings
may have artifacts, e.g. the data were not based on true
the
may not be appropriate for the SOCIety under
Second, the
cultural variables and mental disorder may be mediated by the third variable.
Cultural contents
. Taboos may relate to

banned in any
psychological
sex. aggression,
Lewin (1
that in the culture where
of taboos. mental disorders in women tend to be more
common
Social

ｯｲｾ｡ｮｬｺｴｏ＠

create a favorable condition
such as Ul1iempHlnneJm
of mental disorder. One
ｌｖＢＬｈＧｅｾＮｕ＠
and Redlich (

studies on social
was conducted
Based on the data from the treated cases
mental
status was correlated with the incidence of mental disorder. Individuals of low
-social-economic status were more
to be mental
than individuals of
economic status. The data
by
and Redlich were based on treated
case. not true
From this
we do not know whether
who do not come
A similar and more extensive study
for
treatment will have the same
has been conducted in order to know whether there is correlation between social economic
status and mental disorder in people who do not go for psychiatric treatment,(Schwab, Bell,

Cultural Factors in The EtiolDgj'

13

Warheit. & Schwab, 1919). Using a number of dependent measures (a.g. interview,
personality inventories) they found the pattern of findings that is similar to the findings of
Hollingshed and Redlich. People of low social economic status were more likely
categorized as having psychiatric problems.
Although the data regarding the relationship of social economic status and mental disorder
rather consistent , the real cause of this relationship is not clear. To what degree the
difference in community tolerance and social economic status have influence on psychiatric
diagnose. Sinrilnrly to what extent the downward social mobility, or cumulative stress
experienced by lower economic status individuals would be the causes of mental disorder.
These questions need to be answered in future studies.
IS

Sociocultural change
It is hypothesized that cultural change may increase the incidence of mental disorder
(Wallace. 1969). Even though this hypothesis is appealing, however there were only few
studies attempted to test it. Probably the reason for the lack of interest in studying the
effects of cultural change is that the study needs time to detect the change. The effects of
cultural change can not be detected in a short time period.

The first study aimed at investigating the effect of cultural change on mental disorder was
conducted by Goldhamer and Marhall (1953). Using the hospital admission record in
Massachusetts area between ] 840 - 1940. they found that in 100 year period, the rate of
functional psychoses remains constant, despite the culture has changed. Several explanation
for this findings has been proposed. One explanation argued that there was a possibility
that people of 1940 were more tolerant to mental disorder, so the mentally disorder was not
always sent to hospital. Second, Massachusetts was an industrial area which had been so
advanced in technology in 1840, the 100 year lapse did not influence any change in
socioculturcl1 aspects.
If the attention is directed to the effects of sociocultural change in societies where the
change is a process of acculturation of the traditional culture, one could find the support for
the hypothesis that cultural changes cause mental disorder incidence increased. Shore,
Kinzie, Hampson, and Pattison (1973) reported, based on their study on Indian villages, that
the occurrence of mental disorder among younger Indians who had been exposed to "white
culture" was significantly higher than the older Indian who still preserved the traditional
culture. A rather similar phenomenon was also reported by Beaglehole (1969) in reviewing
studies on mental disorder among New-Zealanders. Due to acculturation process, the
native-born Maoris showed a higher rate of mental disorder, as compared to the Maoris of
previous culturated generation. Interestingly this study showed that the sociocultural
changes among Maoris produced changes in pattern of disorder. It was reported that
between 1953-1957 about 46.9% of Maoris admitted to mental hospital were diagnosed as
manic-depressive, and only 23.4 were classified as schizophrenic. With the acculturation
process, the pattern of disorder changed dramatically few years later. The data on mental

Cultural Facton In The Etiology

hospital admissions between 1958 - 1960 incated that the number of schizophrenic cases
among Maoris increased to 40.9%, while manic-depressive decreased to 17.5%. However
the data did not allow us to know for sure whether this change in pattern was due to the

cultural changes or due to changes in criteria of diagnosis.
IMPACTS OF CULTURE ON CLINICAL SYMPTOM
Discussion on this section will be focused on the way cultural factors are related to common
mental disorder (e.g. schizophrenia. manic depressive). and culture-bound syndrome. Which
specific cultural factors that cause disorders remains unknown. There have been some
speculations about the possible cultural factors that lead to different symptoms. HoweveL
there is no supporting data for these speculations. So they will be excluded from discussion.
Common mental disorder
Sanua (1969) reviewed hundreds of studies focusing on impacts of cultural factors on
clinical symptoms of schizophrenia. One conclusion from the review is that schizophrenia is
found in all cultures. and its symptomatology is colored by the culture. Some of the studies
reviewed showed that schizophrenia m primitive African societies is quiter than in the
Western countries. Among Indian schizophrenics. catatonic, body rigidity and negativism
were reported to be very common. Asiatlc schizophremcs were said to be more with drawn
and less
while the southern Italian
showed the reverse of Asiatic
symptoms.
Manic-depressive psychosis has been intensively investigated. Murphy, Wittkower. and
Chance
that
of endogenous depression. mood change during the
found among
insomnia. diminution of interest in social environment. were
In non
countries the
of
is different from European.
found the
of
and of
as the
ones
ｴｲｰｬＬｾｮ＠

With
neuroses, some evidences showed that acute
reactions of
to
short duration are more common in
societies than in advanced societies
1
Social economic status. and race also found to be correlated with
symptomatology of psychoneuroses. Black Americans showed a
level of
depression, and
than the white Americans
Bell, Warheit &

Culture-bound syndrome
Yap (cited from Leighton, 1969) divided culture-bound syndromes into three types of
symptomatology, fear reactions, rage reactions, and dissociation states. Discussion on each
type will be presented below.

Cultural Factors In The Etiology

15

Fear reactions.
"Latah" refers to a kind of disorder where a patient at the beginning of attack repeat their
own words and sentences, then those of others, especially person in authority. Later on
patients repeat words and sentences of other surrounding him. At other times the patient do
the opposite what the others do. The precipitating factor of the attacks is the word snake, or
by tickling. This kind of disorder occurs in Indonesia and Malaysia A rather similar type is
called "imu", the symptomatology is similar but the precipitating factor is the sight of
snake. "Imu" is a disorder that frequently happen in Japan.
"Koro" is another culture-bound syndrome that mostly occurs in South East Asian
countries. The patient of "koro" experiences a severe anxiety due to being afraid that his
penis will with draw into his abdomen.
"Susto" or "magic fright" is a kind of syndrome that has been reported among Central and
South American Indian tribes. The Symptoms are intense anxiety, hyper excitability,
generalized phobias, depression and somatic symptoms.
Rage reactions
"Amok" is a rage reaction syndrome that was found in Indonesia. Malaysia and Philippines.
The patients of "amok" attack almost everything surrounding him. This is a male-type
disorder.
Dissociation states
Trance and possession are examples of dissociation-states-mental disorder. The persons
who see the patients on attack believe that the spirit of outside agencies such as animal,
ancestors. ghost has intruded the patients. The symptom of this disorder are empty face.
change in tone of voice, change in manner of speaking, and staring into space. This disorder
found in Haiti, Philippines and Indonesia.
CULTURE AS DETERMINANTS OF INTERvENTION
There have been a number of criticism addressed to western oriented intervention
techniques. For example Cohen (cited in Lebra, 1976) observed that in making diagnosis
and treatment, there a remarkable lack of direct attention to ethnicity, race, and cultural
identity. Lack of attention and consideration to these cultural aspects have led the
intervention into failures. Yamamoto et.al (Heller, 1981) reported, for example, therapists
tend to conduct treatment in accordance with the value system of the middle class. This
approach has proven ineffective with and discouraging to lower-class patient. A number of
therapists became frustrated because patients did not respond well to this approach.
Therapists discouraged patients from seeking continued therapy after the first meeting. In
responding to the demand for solution, a new intervention techniques been developed.

16

Christmast, Wallace and Edwards (1973) suggested that utilizing the indigenous therapists
seem to solve the problem. Indigenous therapist can communicate wen with the patients
probably due to the similarity of cultural background. Another attempt of intervention has
also been developed. A sociologically based intervention suggest to provide opportunities to
achieve success (e.g. education, jobs) for the lower social economic status persons. This
success will eliminate disorders. In support to this claim Oden (1974) did a study on the
effects of providing education and jobs on the incidence of delinquency. The findings of his
study showed that by providing the education and the jobs delinquency rates reduced
tremendously.
Another cultural factor that may be important determinant for intervention is belief about
the cause of mental disorder. It has been reported in several studies (Lebra, 1976) people in
developing countries tended to attribute the cause of mental disorder to unnatural factors
such as magic power, spirit possession or ghost This same phenomenon also has been
reported to be existed in the modern country. Wintrob (Heller, 1981) reviewed studies
dealing with the belief
of ethnic minorities within the United States in relation to the
causes and appropriate treatment of mental disorder. The findings revealed that there are
two principal causes of
natural and unnaturdl. Natural causes are factors. such as
nutritional imbalance or infection, parental abuse, or stress of
Unnatural causes are
possession or
magic. It was also reported by
Wintrob (HeUeL 1981) that there is a growing interest among "white-subgroups" about
or mediums hip as an effort to undertand mental illness.
the causes of disorder may determine the choice of mental
Wintrob showed that people who believe that the
treatment. Research
tend to recommend to use community healers
causes of disorder are
or doctors.
line of intervention. For
can be used as a
waste of money and time to build community-mental-health centers in the
healers are the best source of
for mental
aims to compare the effectiveness of
.nJ'" m
mental disorder in the area
it will be a
the causes of disorder.
to demonstrate this effectiveness for the purpose of "''''''I5''UI'5
UH•• ' U '.

service.
of social relationship among
warrants attention is the
of social relations may determines the success of
1981) criticized the way American psychiatrist treated
American evaluation
Criticisms were addressed on two areas.
of patients is too often a one-dimensional focus on the individual. This way of.,evaluation
the
of close
ties in ASIan culture. Secondly the f$lIe that
frequently played
therapists is neutral, non jugmental and noncritical toward patients.
This role is alien to Asian countries. The
unit is headed by the patriarch in Asian
in a

Culiural Factors In The Eliology

17

countries. In contrast to American egalitarian values. the relationship are vertical. This
vertical family relationship between therapist and patient requires the therapist to be an
authority figure. The above criticism suggest that in order to have a better intervention, a
more accurate culturally based diagnosis should be matched with culturally sensitive
treatments.

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National Origin. ""'''51